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NOTE::PULL ALL PERA'MS (SEPTIC, WELL, ETC...) IV AKE COPIES FOR FILE <br /> CPre -�i°rl <br /> LAND USE REPORT APP# `5 ig_ 9 -9 5 Rtv�(d <br /> EHD RECEIVED APP.REFERRAL: / -/ b COMPLETE & SUBMIT BY 0?7 — 00 <br /> DATE DATE <br /> ATTN: K a; C— U O n'vk,- I <br /> SITE ADDRESS: 4 <br /> In completing the Land Use investigation, draw all Public Health factors on the exhibit (i.e.: sewage disposal, <br /> water supplies, etc...). Where necessary, on an attached piece of plain paper, draw completed map of area <br /> showing population density, location of house, wind direction, etc.... <br /> Public water: /)e) Public sewage: /Uy <br /> SUMMARY OR COMMENTS: <br /> ` e-/ CJS )n" 41- <br /> O <br /> Cot& <br /> I recommend: Approval Denial Continuance Inspector's Signature0/'1i/6 'r/w� <br /> Supervisor/Lead Senior Comments: <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> OA/I CHECX O T LIST. oojread report? V Correct LAND USE#? <br /> EH 06 06 Rev 1/99 �L/Correct CONDITION(S)? Logged in LAND USE BOOK? <br />